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General NPI Number Information
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NPI Number | 1043859630
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Entity Type | Organization
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Legal Business Name | BEV FONTAINE LLC
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Dates
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Enumeration Date | 12/30/2019
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 5550 FRIENDSHIP BLVD STE 360
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City | CHEVY CHASE
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State | MD
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Zip | 20815-7256
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Country | US
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Telephone | 240-341-1290
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Fax |
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Provider Business Mailing Address
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Address Line | 1410 POWELLS TAVERN PL
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City | HERNDON
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State | VA
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Zip | 20170-5712
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Country | US
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Telephone | 703-955-4923
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Fax | 703-444-3610
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MR. HOSSIEN TALEBIAN
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Credential |
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Telephone | 703-955-4923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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